Ask for an Exception to Policy

How do I ask for an exception to policy?

An exception to policy request must be in writing. You can write a letter or complete a Petition for Exception to Policy form.

Petition for Exception to Policy form 

Please answer all questions on this form and be specific. Complete the Petition for Exception form online.

Once the form is completely filled out, click the submit button at the bottom of the form. Your request will be sent directly to the Appeals Section.

If you have additional documentation that will help support your request, please mail, fax or email the information to the Appeals Section so it can be used when making a decision on your request.

If the request is medical in nature, please provide documentation to prove that the item or service is medically necessary. You will need to include the costs or proposed savings of the request.

Mail, fax or email the additional documentation to:

What information do I need to include in my exception to policy request?

If you choose not to use the Petition for Exception to Policy form and you want to request an exception to policy, write a letter with the following:

List the name, address, and Medicaid number (state ID number) of the person who needs the exception.

• Describe what the person needs.
• Explain why it is needed. If it is medical in nature, include the medical necessity of the item or service.
• Include the costs and/or proposed savings of the request.
• Tell what has been tried in the past with the person.

If a home health agency is requesting an exception to policy on behalf of a consumer, the following should be included, as well as the information listed above:

• Explain the services needed, including the hours requested and the level of care involved.
• Identify what other programs are involved with the consumer, such as waiver, in-home health-related care, etc.
• Describe the cost breakdown, salary, fringe benefits, and mileage of the person who is doing the care.
• Incorporate the plan of care or the plan of treatment.
• Include the past 30 days of care notes.